Knowledge, attitude, and practice toward value-based care among Chinese nurse: a cross-sectional study

In recent years, the concept of value-based care (VBC) has gained significant attention in the global healthcare sector. Value-based healthcare was first proposed by Michael Porter and his colleagues in 2006. It is a model of healthcare management aimed at meeting patient needs and achieving optimal health outcomes through the provision of high-quality and cost-effective healthcare services, while also managing the use of medical resources efficiently [1]. Currently, China began piloting a new payment model in 2019: Disease-Related Groups (DRG) payment, which has evolved into a mainstream payment method. While notable achievements have been made in the implementation of the DRG reforms, some issues have gradually emerged. As DRG is a prepaid medical insurance payment method, hospitals are responsible for covering any medical expenses that exceed the amount allocated for the patient's diagnosis group. Consequently, to maintain profitability and ensure sustainable development, hospitals may reduce necessary services or add unnecessary ones, potentially compromising patient health [2, 3]. Therefore, experts have proposed incorporating the concept of value-based healthcare into the DRG reform, shifting the DRG payment system from one driven by service volume to one driven by value [4]. Nurses, as integral members of healthcare teams, play a crucial role in the successful implementation of VBC [5]. However, there is a lack of research exploring the knowledge, attitudes, and practices (KAP) towards VBC among Chinese nurses.

This study aims to describe the current status of Chinese nurses' knowledge, attitudes, and practices (KAP) towards value-based healthcare, providing evidence for its implementation in China.

This study describes the current status of Chinese nurses' KAP (knowledge, attitude, and practice) towards value-based healthcare(VBC).In the ‘knowledge’ section, only half of the research subjects are aware of VBC, but they have a correct understanding of its concept. Most of them believe that the level of value is not directly related to the hospital's income level, and that low value healthcare does not mean cheap healthcare. Because the value itself refers to the improvement of patient health outcomes per unit cost. The limited awareness of VBC among nurses might be attributed to the lack of specific operational guidelines in China. However, the majority's correct understanding and endorsement of the purpose of value-based healthcare suggest that it aligns with the nurses' values and goals for future medical practice.

The research in the attitudinal dimension reveals that the highest rate of agreement among participants is for value-based medicine-related courses, indicating that relevant courses could be developed to enhance nurses’understanding of value-based healthcare.According to research by Kuck et al. [6], The implementation of value-based healthcare in internal medicine is more feasible, indicating that relevant training courses could be initially offered to nurses in internal medicine departments.In addition, because some studies have shown that course information is difficult to find, it is recommended to teach courses through multiple channels and take advantage of online to make it more accessible to more people [7]. The concept of value-based healthcare should also be added to the curriculum training of medical students, so as to better promote value-based medicine [8]. Meanwhile, many participants expressed a lack of confidence in providing high-quality medical services, which may be due to the lack of a clear definition of what constitutes high-value and low-value medical services, as well as the absence of quantitative indicators for measuring value. At present, the mainstream method is to form a negative list through various physician associations, and then measure the degree of low-value services through the negative list [9]. In addition, many research subjects believe that digital transformation plays a key role in the promotion of value-based healthcare, because the informatization of Chinese hospitals is still insufficient, the quality of the homepage of medical records is not high, and it may be difficult to measure low-value services, and only a few low-value services can be measured [10, 11]. In addition, concerns about the increased management costs associated with VBC may be due to the lack of clarity about the cost and effectiveness of training, as training will certainly bring a lot of money and time costs, but there is a lack of training and practice in value-based medicine [12].

In practice, the study found that the reported incidence of low-value services was generally over 5% for both nurses’self-reports and reports about their colleagues, indicating a considerable number of low-value services in China. At the same time, there is a discrepancy between the incidence of low-value behaviors reported by nurses themselves and the incidence of low-value practices they reported among their colleagues, with the incidence of low-value services reported by nurses themselves being lower than that reported about their colleagues. This may be attributed to self-other moral bias, where nurses tend to believe that their own medical behaviors do not constitute low-value services when judging whether their own or their colleagues' actions are such services [13]. Among unnecessary medical practices, the incidence of ‘unnecessary laboratory testing’is relatively high.This may be due to the fact that laboratory testing is one of the most frequently performed activities in healthcare, and most tests are overused. The results of these tests either do not alter treatment decisions or can lead to errors in judgment, thereby posing risks to patients [14]. Additionally, among other low-value practices, ‘Insufficient Treatment’is reported relatively frequently.This may be because DRG payment is a prepaid healthcare payment method, where hospitals are responsible for the medical expenses that exceed the diagnostic group the patient is assigned to. Therefore, in order to obtain profits and ensure sustainable development, hospitals may reduce necessary service items or increase unnecessary ones, ultimately leading to impaired patient health.

The limitations of this study include: 1) The use of an online questionnaire format, which may introduce bias; 2) Reliance on self-reported data, which may be subject to inaccuracies; 3) A limited number of objective questions in the knowledge dimension, which may result in an imprecise exploration of understanding of value-based healthcare. Despite these limitations, this study is the first to conduct a KAP survey on value-based healthcare among Chinese nurses, featuring a multi-center and diverse sample, which adds significant value to the research.Future research could consider using offline questionnaires, incorporating hospital system data, and increasing the number of objective questions in the knowledge dimension to better reflect the actual situation.

This study is based on a survey of knowledge, attitudes, and practices (KAP) regarding value-based healthcare among nurses, and it has found that Chinese nurses currently have limited understanding of value-based healthcare. Furthermore, according to the research findings, there may be low-value healthcare practices in China, such as "unnecessary laboratory tests" and "insufficient treatment." Additionally, it was discovered that the incidence of low-value practices reported by nurses themselves was lower than that reported by their colleagues. These research findings suggest that promoting nurses' awareness of KAP through department-specific gradual promotion and online publicity, as well as investigating low-value healthcare practices using objective data such as hospital system data, could be effective strategies. This would facilitate the implementation of value-based healthcare in China and address potential deficiencies that may arise from new healthcare payment methods.